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Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis
  1. Soffien Chadli Ajmi1,2,
  2. Martin W Kurz1,3,
  3. Hege Ersdal2,4,
  4. Thomas Lindner4,5,
  5. Mayank Goyal6,
  6. S Barry Issenberg7,
  7. Corinna Vossius8
  1. 1Department of Neurology, Stavanger University Hospital, Stavanger, Norway
  2. 2Faculty of Health Sciences, Universitetet i Stavanger, Stavanger, Norway
  3. 3Institute of Clinical Medicine, University of Bergen, Bergen, Norway
  4. 4Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
  5. 5The Regional Centre for Emergency Medical Research and Development, Stavanger, Norway
  6. 6Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  7. 7The Gordon Centre for Research in Medical Education, University of Miami Miller School of Medicine, Miami, Florida, USA
  8. 8Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
  1. Correspondence to Dr Soffien Chadli Ajmi, Department of Neurology, Stavanger University Hospital, Stavanger, Norway; soffiena{at}


Background Rapid revascularisation in acute ischaemic stroke is crucial to reduce its total burden including societal costs. A quality improvement (QI) project that included streamlining the stroke care pathway and simulation-based training was followed by a significant reduction in median door-to-needle time (27 to 13 min) and improved patient outcomes after stroke thrombolysis at our centre. Here, we present a retrospective cost-effectiveness analysis of the QI project.

Methods Costs for implementing and sustaining QI were assessed using recognised frameworks for economic evaluations. Effectiveness was calculated from previously published outcome measures. Cost-effectiveness was presented as incremental cost-effectiveness ratios including costs per minute door-to-needle time reduction per patient, and costs per averted death in the 13-month post-intervention period. We also estimated incremental cost-effectiveness ratios for a projected 5-year post-intervention period and for varying numbers of patients treated with thrombolysis. Furthermore, we performed a sensitivity analysis including and excluding costs of unpaid time.

Results All costs including fixed costs for implementing the QI project totalled US$44 802, while monthly costs were US$2141. We calculated a mean reduction in door-to-needle time of 13.1 min per patient and 6.36 annual averted deaths. Across different scenarios, the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29, and the estimated costs per averted death ranged from US$4679 to US$10 543.

Conclusions We have shown that a QI project aiming to improve stroke thrombolysis treatment at our centre can be implemented and sustained at a relatively low cost with increasing cost-effectiveness over time. Our work builds on the emerging theory and practice for economic evaluations in QI projects and simulation-based training. The presented cost-effectiveness data might help guide healthcare leaders planning similar interventions.

  • simulation
  • quality improvement
  • cost-effectiveness
  • medical emergency team

Data availability statement

All data deemed relevant to the study are included in the article or uploaded as online supplemental information. Additional supporting data are available on reasonable request.

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Data availability statement

All data deemed relevant to the study are included in the article or uploaded as online supplemental information. Additional supporting data are available on reasonable request.

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  • Contributors SCA is the corresponding author. SCA, MWK, HE and CV contributed to the conceptualisation, design of the study in addition to analysis and interpretation of data for the work. TL, MG and SBI contributed to the analysis and interpretation of data for the work. SCA drafted the work and MWK, HE, CV, TL, MG and SBI contributed with multiple critical revisions. SCA is responsible for the overall content as guarantor.

  • Funding This study was funded by Universitetet i Stavanger (Safer Healthcare Grant (Number: Not applicable)).

  • Competing interests SCA is a research fellow funded by a Safer Healthcare Grant (University Research Fund). Otherwise, the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. MG has a consulting agreement with Mentice. The remaining authors report no disclosures.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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